complaint·June 23, 2023

The administrator stated they had forgotten to destroy the medication. LPA requested destruction records for previous residents and found that that R2 had a documented destruction record for medications. During the time of the visit, the administrator destroyed R1’s medication and documented this. Due to medication being found during the time of today’s visit that the administrator failed to destroy, the allegation is substantiated. Regarding “Staff left resident in soiled clothing for extended amount of time.”, it was alleged that overnight staff at the facility were not changing resident and as a result were left soiled overnight. LPA interviewed night staff at the time of the visit who stated that residents were changed every 2 hours, including overnight. They stated R3 was the only incontinent resident at this time of the interview, June 23, 2023. LPA reviewed the incontinence accountability log for R3 and found that on several occasions the resident was not documented as changed after 5pm, with next time changed as 5am. Therefore the allegation is substantiated. A finding of substantiated means the preponderance of the evidence standard has been met. Substantiated finding was cited under Title 22 Division 6 Chapter 8. Plan of correction was made with the administrator. An exit interview was conducted with administrator, Ana Stark where this report, LIC9099-D and appeal rights were reviewed and provided to them. LPA interviewed the administrator and (1) staff present during today’s visit, who stated that a protein is served to the resident every day. LPA observed during the visit that resident were fed protein for lunch. Therefore, the allegation is unsubstantiated. Regarding “Staff used resident's personal care products on other residents”, it was alleged that staff used private pay residents supplies when the facility ran out. LPA interviewed staff and administrator during the time of the visit who stated that all current residents provide their own supplies. The administrator stated they have a subscription service with Amazon since the facility opened, and receive incontinent supplies on a monthly basis. LPA observed the facility’s incontinent supplies and found that there were enough supplies to be used in case resident ran out of their supplies. LPA also observed (3) resident rooms for incontinent supplies and found that had extra supplies in their room, including supplies that the administrator had supplied them. Therefore the allegation is unsubstantiated. Regarding “Staff failed to protect resident from sustaining injury.” It was alleged that R4 had gone to the liquor store and bought liquor, had become intoxicated at the facility, which resulted in a fall and stitched to R4 forehead. LPA interviewed administrator who stated that the resident only went on supervised outings to the store, with them and staff 1 (S1). They stated that R4 did not purchase alcohol during their time at the facility. R4 is unable to be interviewed as they are now deceased. LPA interviewed S1 during the time of the visit who stated that R2 did sustain a fall where the resident had to have stitched to their forehead, but that this fall had occurred at night when the resident got up to go to the bathroom. LPA could not find any evidence to corroborate the allegation. Therefore, the allegation is also unsubstantiated. A finding of unsubstantiated means that although the allegation is valid, the preponderance of the evidence standard has not been met. An exit interview was conducted where this report was reviewed and provided to Administrator, Ana Stark.